In the News for the Week of 3-15-05
- College offers free "Welcome to Medicare" exam tools
- Coming in April: Recertification credit for new MKSAP modules
- ACP: Congress shouldn't adopt MedPAC lab value recommendation
Clinical news in the headlines
- TIAs often precede major strokes
- Study bolsters case for using high-dose statins
- Aspirin protects women from strokes but not heart attacks
- Highlights of Annals of Internal Medicine
- Study highlights flaws in implementing CPOE systems
- CMS debuts one-stop Web resource for physicians
College members now have free access to screening tools approved by the CMS to use in the new "Welcome to Medicare" exam.
The CMS has defined elements that must be part of the initial preventive exam and those elements include screening for depression and functional ability/level of safety. The CMS rules also require that physicians conduct those specific elements by using screening tools or instruments that are recognized by medical societies such as ACP.
The new preventive exam, launched by Medicare on Jan. 1, 2005, now covers all patients within the first six months of their enrollment in Medicare Part B. The College has compiled ACP-approved screening tests for depression, functional ability and level of safety on a user-friendly Web page on ACP Online. The materials are drawn from PIER, the College's Web-based, clinical decision support tool; MKSAP 13; and Annals of Internal Medicine.
The screening resources may be found on ACP Online.
For more information on the newly covered exam, see "How to bill for the new 'Welcome to Medicare' exam" in the Jan.-Feb. ACP Observer.
Beginning in late April, MKSAP 13 subscribers who are enrolled in ABIM's maintenance of certification program will be able to access newly configured electronic MKSAP modules for credit toward recertification. A major feature of the new modules will be immediate feedback, letting physicians know if they have answered each question correctly and linking each question to extensive educational material.
Four specially selected MKSAP question modules will each contain 60 questions and will be available on ACP Online. Current MKSAP subscribers enrolled in ABIM's recertification program will be able to download and complete these modules at no additional charge. Candidates will receive the same amount of credit for completing each new MKSAP module as any of the ABIM self-evaluation process modules.
Physicians can get credit for completing up to a maximum of four of the new MKSAP modules.
You can order MKSAP 13 online or by phone at 800-523-1546, ext. 2600. Look for more information on the ABIM-approved modules in late April.
Five health care organizations, including ACP, have asked Congress not to act on a recent recommendation made by the Medicare Payment Advisory Commission to have lab values submitted with claims. Congress would have to change the Medicare law to implement the MedPAC recommendation.
Adopting that recommendation, ACP said in a March 3 letter to the chair of the Senate Finance Committee, would be premature. That's because there are currently no uniform standards for coding and transmitting lab data.
Without such standards, moving to approve the recommendation would increase administrative burdens and costs for physicians, insurers and labs, while slowing down the claims reimbursement process.
Labs would have to retool their current billing and result-reporting systems, an expense that may cause small independent labs to shut down. Physician practices currently don't integrate their clinical and billing information systems, and extensive education would be needed, the letter said, to ensure accurate coding of lab data in medical records.
The letter was signed by ACP, as well as the American Academy of Family Physicians, the American Clinical Laboratory Association, Blue Cross Blue Shield Association and Medical Group Management Association.
The letter is online.
Clinical news in the headlines
A study published last week found that most transient ischemic attacks (TIAs) occur up to a week before a stroke, suggesting that preventive measures should be taken after TIAs to avoid a major attack.
While previous studies have established that TIAs often precede strokes, physicians have been uncertain about when to intervene with preventive treatment. This study, which was published in the March 8 Neurology, concluded that major strokes most often occur just hours or days after a TIA.
In the study, 23% of the 2,416 patients who suffered an ischemic stroke reported experiencing a preceding TIA, according to the Neurology abstract. Of those, 17% occurred on the day of the stroke, 9% on the previous day and 43% during the seven days leading up to the stroke.
Researchers did not find any risk factors or characteristics that would help predict which TIA patients would suffer a stroke within this short timeframe. However, the study's authors noted that preventive treatments should be started within hours of a TIA to be most effective.
The Neurology abstract is online.
New study findings released last week provide compelling evidence that taking high doses of statins to reduce LDL cholesterol to very low levels may provide the best protection against heart attacks and strokes.
In the study, 10,000 patients with heart disease and LDL cholesterol levels of less than 130 mg per deciliter received either 10 mg or 80 mg daily of atorvastatin. After a median of 4.9 years, patients in the 10 mg group had reduced their LDL cholesterol to 101 mg per deciliter while those taking 80 mg had an average level of 77 mg per deciliter.
Researchers reported a 22% relative risk reduction in the rate of major cardiovascular events in the 80 mg group vs. those taking 10 mg. The study—funded by Pfizer Inc., which sells atorvastatin—will appear in the April 7 print edition of New England Journal of Medicine (NEJM), but was posted early online.
The findings may encourage physicians to use higher doses of statins and may lead to new official recommendations on lowering cholesterol, according to the March 9 Washington Post. Last July, the National Cholesterol Education Program (NCEP) stopped short of changing its official recommendation to aim for an LDL cholesterol level of 100 mg per deciliter or less in patients at high risk for heart disease.
The Washington Post noted, however, that the panel at that time said it might change its official recommendation pending the results of three large studies. Those studies include this atorvastatin study and two others still underway.
While the study found that taking high statin doses lowers overall risk for cardiovascular events, the authors noted that there was no difference between the two groups in overall mortality. While some will interpret these results as reason to be more aggressive with statins, the NCEP chair told the Washington Post that physicians shouldn't move toward more aggressive statin treatment until results of the other two trials are released.
The NEJM abstract is online.
The Washington Post is online.
Daily low-dose aspirin lowers women's risk of stroke but does not prevent heart attacks, according to a new study released last week. Those findings are the opposite of what is known about aspirin's effects on men.
In the Women's Health Study, which followed almost 40,000 women age 45 or over for 10 years, participants were assigned to receive either 100 mg of aspirin on alternate days or placebo. Researchers reported a 17% reduction in stroke risk and a 24% reduction in ischemic stroke risk in the aspirin group compared with those on placebo group.
Aspirin had, however, no significant effect on the risk of fatal or nonfatal myocardial infarction. The results will be published in the March 31 print issue of New England Journal of Medicine (NEJM) but have been posted early on the journal's Web site.
By contrast, in studies involving men, aspirin has caused a significant reduction in the risk of myocardial infarction but no significant reduction in strokes, the researchers reported. The results, they said, highlight the importance of studying women as well as men in clinical trials, and the need for physicians to consider individual risk profiles when deciding whether to recommend aspirin.
Women in the study had more strokes than heart attacks (487 vs. 391), which may explain why heart disease is often viewed as a bigger problem for men, according to the March 8 New York Times. Researchers do not know why aspirin affects men and women differently, the article said, but experts say it may be related to the size of blood vessels leading to the brain, which are smaller than those leading to the heart.
The study found that aspirin is more effective in reducing the risk of major cardiovascular events in women older than 65. Researchers noted, however, that gastrointestinal bleeding was a significant side effect of aspirin, and emphasized that the risks of taking aspirin may not balance the benefits for women at low risk for heart disease.
The NEJM abstract is online.
The New York Times is online.
The following articles appear in the March 15 issue of Annals of Internal Medicine. Full text is available to College members and subscribers online.
Study: Fewer calories—not fewer carbs—lead to weight loss. A three-week, in-hospital study of 10 obese volunteers with mild type 2 diabetes mellitus compared a usual diet to a very low-carbohydrate diet.
During the first study week, participants ate about 3,000 calories and 300 grams of carbohydrates per day and remained at entry weight. In the following two weeks, participants were restricted to 20 grams of carbohydrates per day (as specified in the Atkins induction diet) and voluntarily ate one-third fewer calories than during the first study week. Participants lost an average of 3.6 pounds over that two-week period.
Researchers concluded that the weight loss came from fewer calories as a result of eating less, not from loss of body fluid, increased metabolism or boredom with the food selection. An editorial noted, however, that the study was small and lasted only three weeks.
Borderline risk factors account for only small proportion of CHD deaths. Data from two large health studies show that borderline levels of risk factors for coronary heart disease (CHD) account for only a small percentage of CHD events.
More than 90% of CHD events studied took place in patients with elevated levels of one or more risk factors. Fewer than 10% occurred in patients of either sex who had borderline risk factors. Nearly one-sixth of the CHD events in men and one-tenth in women occurred before age 55.
An accompanying editorial claimed that the results do not support a strategy of giving all adults over age 55 a "polypill," which would contain low doses of several drugs to modify CHD risk factors.
New study findings released last week concluded that computerized physician order entry (CPOE)—long touted as a way to reduce medication errors in hospitals—may lead to more medical errors as physicians and other health care workers adjust to using them.
The study, which was supported by the Agency for Healthcare Research and Quality (AHRQ), identified 22 situations in which using CPOE increased the risk of errors, according to a March 8 AHRQ press release. Those situations include:
A CPOE system may reflect only dosages available at the pharmacy, which may differ from minimum or usual dosage. That system flaw could result in inappropriate dosing.
Providers might choose the wrong patient file because names and drugs are hard to read on some CPOE systems and patients' names do not appear on all screens.
A patient's medication information may not be summarized on one screen and physicians may have to check up to 20 screens to see all of a patient's medications.
Nurses often don't have time to enter timely information about drug administration, which can affect later clinical decisions.
Computer downtime can result in delays in getting drugs to patients.
According to the AHRQ release, the findings highlight the importance of testing and refining CPOE systems during their early implementation.
The study appeared in the March 9 Journal of the American Medical Association (JAMA). It was based on interviews, focus groups and surveys of medical personnel at a major urban teaching hospital with a widely used CPOE system.
Full text of the JAMA article is online.
The AHRQ press release is online.
Medicare has launched a new Web site that gives physicians quick access to the latest Medicare news as well as payment, billing and regulatory information.
The Physician Information Resource for Medicare, which the CMS developed with the American Medical Group Association (AMGA), was designed as a one-stop resource for Medicare fee-for-service information, according to a March 10 AMGA news release. The site includes sections on coding, HIPAA compliance and fraud, as well as a quarterly provider update.
The site highlights recent changes in Medicare rules and directs providers to other resources. Currently posted, for example, is a Medlearn Matters article advising doctors on what to do about an October 2004 CMS software change that led to a sharp rise in claim denials due to mismatched provider names and numbers. Physicians can also link to CMS manuals and the latest fee schedule and drug prices.
The Physician Information Resource is on the Medicare Web site.
The AMGA news release is online.
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Copyright 2005 by the American College of Physicians.
A 67-year-old man is evaluated for a 6-month history of worsening exertional dyspnea. He has severe COPD, previously with minimal exertional symptoms, but now notes activity-limiting shortness of breath when walking short distances. He does not have chest pain, gastrointestinal symptoms, or sleep-related symptoms. Medical history is otherwise unremarkable. Medications are a twice-daily fluticasone/salmeterol inhaler and an as-needed albuterol/ipratropium metered-dose inhaler. He has a 55-pack-year smoking history but quit when COPD was diagnosed. Following a physical exam, chest radiograph, and transthoracic echocardiogram, what is the most appropriate diagnostic test to perform next?
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